Provider Demographics
NPI:1811479736
Name:THIES, NICOLE CATHERINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CATHERINE
Last Name:THIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:CATHERINE
Other - Last Name:GOSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3816 E HUNTINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-6360
Mailing Address - Country:US
Mailing Address - Phone:507-381-6325
Mailing Address - Fax:
Practice Address - Street 1:1210 W 18TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4650
Practice Address - Country:US
Practice Address - Phone:605-312-8500
Practice Address - Fax:605-312-8501
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant